Effective Treatment of Sleep Problems for Children with ASD

Transcription

1 Effective Treatment of Sleep Problems for Children with ASD Dennis R Dixon, Ph.D. Center for Autism & Related Disorders, Inc.

2 Normal Sleep What is Sleep? Sleep is a brain process Yet effected by environmental factors operant contingencies Sleep is an active process Not just a response to fatigue Sleep is not a single process Multiple systems work together to create sleep/wake

3 3 Systems of Sleep Regulation Nervous system activation Sympathetic vs. parasympathetic Example: conditioned anxiety Sleep debt Drive state (hunger, thirst) Purpose is not to relieve sleepiness Circadian Rhythm Internal biological clock to regulate systems hour cycle Core body temperature Max alertness near peak temperature (2pm) Cycle is reset daily by bright light

4 Basics of Biological Rhythms Timing is everything Zeitgebers Day/night Ambient temperature Food availability Physical activity Social cues Entrainment by Light

5 Sleep and Age Sleep patterns change over the lifespan Babies sleep twice as much, but at irregular intervals Intervals begin to consolidate Total sleep time begins to decrease

6 Age 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years Total Hours of Sleep Suggested Nap Hours 1-3 hours (1 Nap) 1-3 hours (1 Nap) hours (0-1 Nap) hours (0-1 Nap) None None None None None None None None None None None None None

7 Why Does Sleep Matter? Sleep has a broad effect across many of the day-to-day aspects of an individual s life Poor sleep is associated with irritability, mood, concentration, memory, and learning problems Sleep problems may be the result of a medical condition, side effect of medication, poor sleep hygiene, or a psychological disorder Benca, 2000; Gillin & Drummond, 2000; Smith, Smith, Nowakowski, & Perlis, 2003; Uhde, 2000

8 Medications and Sleep Problems Many medications will impact sleep Blood pressure medications Clonidine, propranolol, atenolol, methyldopa Hormonal Thyroid, cortisone, progesterone Long-term use of antihistamines Asthma Theophylline, albuterol, salmeterol SSRI antidepressants Fluoxetine, paroxetine Steroids Prednisone Stimulants Methylphenidate, amphetamines

9 Why Does Sleep Matter? Sleep problems are common Often associated with emotional disorders or stressful life events Ford & Kamerow, 1989 Patients with chronic sleep disorders have been found to be at an increased risk for depression, anxiety disorders, substance abuse disorders, and nicotine dependence Breslau, et al. 1996; Ford & Kamerow, 1989 Improvements in mood may often be found when treating the underlying sleep problem Jacobs, et al. 1993; Jacobs, et al. 2004

10 Why Does Sleep Matter? Sleep problems occur frequently among children with ASD 40-80% Parents rank sleep problems among the most common and important problem. Risk of accidents

11 Why Does Sleep Matter? Other issues reported: Hyperactivity Disruptive behavior Communication difficulties Social difficulties Difficulties breaking routines All of these problems may impact learning during the day

12 Why Does Sleep Matter? When your child doesn t sleep well, nobody sleeps well!

13 Sleep in Children with ASD Sleep problems predict overall autism scores and social skills deficits (Schreck et al 2004) Hours of sleep per night predict: autism severity social skills deficits stereotypic behavior Sensitivity to environmental stimuli and screaming predict communication problems

14 Sleep Disorders vs. Sleep Problems

15 Types of Sleep Disorders Dysomnias Dysomnias consist of problems related directly to the sleep process amount, quality, and timing of sleep Parasomnias Consist of problems that occur during sleep or sleep-wake transitions

16 Dysomnias: Primary Insomnia Prevalence rates of insomnia follow a developmental course in which persons in early childhood and older adulthood are more likely to experience this problem Persons with primary insomnia appear to be hyperaroused (Hauri, 2000) It is not particularly the inability to fall asleep that is found distressing, but rather it is the consequences of getting too little sleep that are seen as the problem Lack of sleep can increase irritability, lead to excessive daytime sleepiness, or impair functioning (Zorick & Walsh, 2000)

17 Insomnia in ASD Most common type of sleep problem among children with ASD Types of insomnia problems: Sleep onset Length of sleep Early morning wakening Irregular sleep-wake cycle Poor sleep routines

18 Insomnia in ASD Behavioral Causes Sleep-Onset Using sleep aids to help a child fall asleep may actually make things worse Develop dependency upon the conditioned state Unable to fall back to sleep without it Limit-Setting Behavioral routines and enforcing bedtimes

19 Insomnia in ASD Non-Behavioral Causes Gastrointestinal Problems GI problems can be painful - May lead to night awakenings and fragmented sleep (Ming, 2008) Seizures Malow, 2004 Sleep deprivation may promote seizure activity Anxiety & Depression

20 Insomnia in ASD Circadian Rhythm Dysfunction Melatonin Naturally occurring hormone Regulates circadian rhythm Seasons 10% of children with ASD show some sign of seasonal sleep problems (Giannotti, 2008) Hayashi (2000) sleep journal from a child with autism showed moderate problems in Jan-June, none in July-August, major increase Oct-Dec daylight savings time

21 Dysomnias: Primary Hypersomnia Sleepiness will wax and wane throughout the day (Mitler & Miller, 1996) Decreased alertness during the mid-afternoon (2:00 pm) Severe decrease during early morning (2:00 am) corresponds to a peak in body temperature and a significant drop in body temperature, respectively Severe cases of excessive daytime sleepiness are frequently associated with obstructive and central sleep apnea, restless leg syndrome, and neurodegenerative diseases (El-Ad & Korczyn, 1998) Typically not reported as a significant problem in ASD

22 Dysomnias: Breathing-Related Sleep Disorder Breathing-Related Sleep Disorder Apneas (breathing cessation) Hypopneas (slow or shallow breathing) Hypoventilation (low oxygen blood levels) Types: obstructive, central, and central alveolar hypoventilation

23 Sleep Apnea in ASD ASD not a particular risk for BRSD Relatively easy to treat in some cases Malow (2006) Adenotonsillectomy resulted in improvement across multiple domains Social functioning, concentration, repetitive behaviors, auditory sensitivity

24 Dysomnias: Circadian Rhythm Sleep Disorder Circadian Rhythm Sleep Disorder Desynchronization of sleep cycle with environmental cues Unable to sleep when it is desired or socially expected

25 Parasomnias Sleep Terror Disorder Showing signs of acute terror: screaming, crying, shouting Not related to psychopathology Unknown cause May be genetic

26 Other Disorders in ASD Non-REM Arousal Disorders Aberrant Arousals from NREM Confusional arousals, sleepwalking Risks: sleep deprivation, illness, stress, apnea REM Sleep Behavior Disorder Acting out dreams Risks: medications Rhythmic Movement Disorder Primarily seen during sleep transitions Repetitive movements: head, trunk, limbs

27 Treatment Two treatment approaches Pharmacological Behavioral

28 Pharmacological Treatments Should be used as second-line treatment for sleep problems in ASD Avoid over the counter medications like antihistamines Benadryl is not a medication for sleep! Medications should target the underlying cause of the sleep problem, not just sedate the child

29 Pharmacological Treatments Melatonin Naturally occurring hormone Considered a nutritional supplement by FDA Available over the counter Regulates circadian rhythm May only be working as a hypnotic and not entraining sleep cycle Van den Heuvel, et al. 2005

30 Pharmacological Treatments Melatonin May be deficient in children with ASD Ritvo et al. 1993; Nir et al. 1995; Kulman et al. 2000; Tordjman et al Initial results support the use of melatonin Few controlled studies Not rigorously tested for safety

31 Pharmacological Treatments Little data to support use of other medications (Johnson, Giannotti, & Cortesi, 2009) If child is already taking a medication for another condition, consider the timing of the sedative effects

32 Behavioral Treatments Behavioral Treatment tools Bedtime Scheduling Bedtime Routine Sleep Hygiene Light Therapy Faded Bedtime Chronotherapy Extinction Morning Positive Reinforcement Bedtime Pass

33 Behavioral Assessment Functional Analysis is the gold standard Brown & Piazza (1999) Suggest the use of FA in the treatment of sleep disorders Failure of treatment may be due to lack of matching treatment to function of the sleep problem

34 Time In bed Sleeping Crying Parent s Behavior 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM Tracking 10:00 PM sleep 10:30 PM problems 11:00 PM 11:30 PM 12:00 AM 12:30 AM Insert 1:00 AM table 1 here. 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM Behavioral Assessment

35 Bedtime Scheduling Consistency matters Same bedtime everyday Same naptime everyday Same wake time everyday Giving in on these will make the problem worse Why it works: Sleep debt Entrainment of circadian rhythms

36 Bedtime Routines Like consistent scheduling, forming a routine can be very effective and should be a foundation to any treatment Children with ASD typically respond well to routines Low cost to implement Typically a component of treatment but not implemented alone Adams & Rickert, 1989; Allison et al, 1993

37 Bedtime Routines The activities are less important than the actual routine itself Quiet and calming activities Read a book instead of power rangers videos Fixation on the routine may become a problem (Kodak & Piazza, 2008) Insert subtle variety into the routine Example: Switching pajamas

38 Sleep Hygiene Get up at the same time everyday Bedroom is free of noise Bedroom is at a comfortable temperature Eat regular meals don t go to bed hungry Avoid excessive liquids in evenings Cut down on all caffeine products Your child s bed is only for sleep, not playing in Avoid long naps Exercise regularly

39 Light Therapy Light therapy is a promising intervention for treating various sleep problems Primarily for insomnia or circadian rhythm disorder Relatively easy and inexpensive Exposure to bright natural or artificial light Takes advantage of the strong role that light plays as a zeitgeiber Daily exposure to light for approx 2 hours for two weeks Shown to be effective for treating fragmented sleep Following unsuccessful treatment attempts with sleep hygiene as well as hypnotic medication Short & Carpenter 1998; Altabet, et al. 2002

40 Faded Bedtime Set bedtime during period in which the child is likely to fall asleep quickly (within 15 minutes) If the child falls asleep within 15 minutes, move the bedtime earlier by 30 minutes for the next day If not, move bedtime back 30 minutes

41 Faded Bedtime Piazza et al. (1991) 4 y.o. girl with autism Bedtime disruptions, night waking, excessive daytime sleepiness Faded bedtime for 10 nights Significantly improved night sleep time Significantly decreased daytime sleep

42 Faded Bedtime Piazza et al. (1997) 14 children (3 with ASD) Target Behaviors: Early waking, night waking, delay to sleep onset 2 of 3 with ASD sleep problems totally eradicated

43 Faded Bedtime Recommended for: Delayed sleep onset Fragmented sleep Considerations: Easy to implement with guidance Data tracking can be tricky Must be willing to keep child awake throughout the day No matter how tired they are!

44 Chronotherapy Developed as a treatment for delayed sleep phase syndrome Each day the individual s bedtime is pushed back by one to two hours This is continued until the appropriate bedtime is reach Piazza, et al. (1998) Used of chronotherapy to effectively reduce sleep problems in an 8 year-old girl with autism Considering the overall burden of this approach, other less disruptive methods may be preferred

45 Extinction Caregiver must ignore all challenging behavior Let the child cry it out Place back into bed without giving attention Ignore complaints or other verbal behavior

46 Extinction Effective but hard to implement correctly Implementing incorrectly will make the problem much worse Giving in simply teaches the child to cry longer/louder Caregiver fatigue Safety concerns Noise concerns

47 Morning Positive Reinforcement Goal: reinforce the behavior of waking-up in own bed Primarily for co-sleeping Child receives positive reinforcement for sleeping in his/her bed through the night Requires Extinction if child attempts to sleep in another location they are redirected back to their bed

48 Bedtime Pass Goal: Increase compliance with going to bed (and staying) For bedtime refusal Child is given a pass to leave bedroom Set number of passes per night Gives up one pass for each time leaving Reduce the number of passes given per night as bedtime refusal is reduced

49 Bedtime Pass